"What guides us here?" Exploring community health nurses' experiences of moral distress

Abstract

The concept of moral distress was first developed in the mid 1980’s by the American philosopher Dr. Andrew Jameton. Since then, moral distress has been studied in many health care practice settings and among various disciplines. However, moral distress among nurses in community health care settings has remained largely unexplored. Community health nurses (CHNs) work with clients, families, and communities with a variety of diverse care needs. Therefore, in this research I cast a wide net by asking a broad question, “What guides us here?” What guides nurses through the ethical landscape of community health nursing? The purpose of this research, then, is to explore CHNs experiences of everyday ethical issues and moral distress and identify educational opportunities for ongoing learning and support. To do this I used a narrative inquiry approach and interviewed 20 Canadian CHNs by phone. Based on my analysis of the data, categories of key ethical issues, themes, and educational needs were explored and identified. From the interview data, participants’ stories were then re-storied by me into meta-narratives. Nine meta-narratives, inspired by multiple-participant interview responses, were created as an end product of this study. The meta-narratives represent stories that are true to life in the details regarding situations that the CHNs reported from their nursing practice. At the same time, however, the meta-narratives do not describe any one situation; rather they reflect aspects of several stories combined. Thus, the meta-narratives offer protection of confidentiality, provide an evidence-based, detailed account of these experiences, and are educational resources for CHNs. I also designed and had participants evaluate an educational intervention in the form of a self-directed e-learning module (e-module). Based on the research findings, I offer recommendations for action to promote ethical nursing practice and support CHNs, which include implications for education, theory, research, and nursing practice. This research provides foundational knowledge about the ethical landscape of community health nursing in Canada, the everyday ethical issues faced, experiences of moral distress, and educational opportunities to support CHNs.